Refer a Client
Complete this form to refer a client for mental health services. In-office and online appointments are available across California. The Haven at College accepts clients over the age of 18.
Client First Name
*
Client Last Name
*
Client Email
example@example.com
Client Phone Number
*
Please enter a valid phone number.
Client Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
University/College (if applicable)
Insurance Provider
Member Policy #
Group #
Is the client aware that they are being referred for mental health or substance use disorder care?
*
Yes
No
What type of service are you requesting for your referral?
*
Intensive Outpatient
Enhanced Outpatient
Group Therapy
Reason for Referral
*
Referring Provider Name
*
Name of Practice/Group/Organization
*
Referral Email
example@example.com
Referral Phone Number
*
Please enter a valid phone number.
Referral Fax Number
Please enter a valid phone number.
Please upload any relevant documentation
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Additional Questions or Comments
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Please verify that you are human
*
DOB
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